Stay alert to patients' suicide risk

Between 2004 and 2010, one of the five sentinel events most frequently reported to
The Joint Commission was inpatient suicide.

Many of those suicides occurred in psychiatric facilities, but 14% took place in non-behavioral
health units of general hospitals and 8% happened in emergency departments, according
to the database of voluntary reports. While psychiatric providers are well aware of
the risk of suicide among their patients, other hospital departments are not specifically
designed to prevent suicides, and their staff members, including hospitalists, typically
have many other priorities on their minds.

Robert Wise, MD

That's why The Joint Commission recently provided a reminder, through a Sentinel Event
Alert on preventing suicide in medical/surgical units and the emergency department.
The alert, available online, lists suicide risk factors and reduction strategies and encourages hospitals to
educate staff about this issue.

ACP Hospitalist recently spoke with Robert Wise, MD, medical advisor to the division of healthcare
quality evaluation at The Joint Commission, about the alert and what hospitalists
can do to reduce the risk of suicide for their patients.

Q: What motivated this alert?

A: This is the second alert we have put out. The first one really dealt broadly with
inpatient suicides, most of those occurring in psychiatric hospitals. In follow-up
discussions and also in looking at our sentinel event database, we saw that a number
of these suicides were occurring outside of psychiatric units, specifically in medical/surgical
units and in the emergency department. The prevention of a suicide in a med/surg unit
is very different than a suicide in a psychiatric unit, so it felt important to differentiate
those differences to hopefully alert people to the need and the problems.

Q: Is the risk of suicide under-recognized in med/surg units currently?

A: The issue is that med/surg units are so focused on treatment of life-threatening medical
situations. Suicide prevention is often not on their minds as a top priority. If you
go on a psychiatric unit, somebody with congestive heart failure may be under-recognized;
it's just not what that staff is most tuned into. This [alert] really helps to encourage
clinicians to become more intentional about this issue. If you think about the possibility,
if you suspect the problem, you're more likely to see it.

Q: What are common indicators of suicide risk on a medical unit?

A: Those are the kinds of issues that are talked about in the alert. If somebody has
an overdose or somebody is in a single-car accident, those in fact may be suicide
attempts. You're starting with an active psychiatric disease that results in a medical
problem. In those types of situations, in an orthopedic unit or an ICU, one should
consider that the etiology was in fact a suicide attempt.

Q: What's the other risk type?

A: The kinds of [medical problems] that have a negative or depressing effect on a person's
state of mind. These conditions can be seen as potential risk factors. You need to
ask yourself the question, ‘How is this medical problem impacting or likely
to impact this person?’ If it is a kind of problem that a person will have
trouble adjusting to, either because it's gone on for so long, it's wearing them out
emotionally, or because they are losing substantial function—it could be intellectually,
it could be physically—you should consider that person possibly at risk. For
instance, somebody who is in chronic pain where there is no relief—that will
have a debilitating impact on the person's emotional state. Eventually they feel exhausted
and think about giving up. Or somebody who has had a major heart attack or a stroke
after they've been very healthy—it appears to them that their life is forever
going to be different in a negative way.

Q: What can physicians do?

A: Not only would you want the physician to consider the impact, but it's something that
should also be told to the nurses, to be aware of the consequences of such a situation.
Are they seeing any behaviors that would make them concerned? It might be more obvious
to the nurse who's going to be around the patient a great deal of time. The doctor's
going to spend less time with the patient. One of the things the physician can do
is alert the nurses to keep their eyes open to worrisome behavior or thoughts.

Q: What are the barriers to focusing on suicide on medical units?

A: Life is so complicated and busy on a medical surgical unit. The issue is how to give
needed training, how to get people to include suicidality into their thinking about
certain patients. A number of years ago, The Joint Commission started to talk about
the issues of awareness of pain in patients. That type of thinking is now well integrated
into the ongoing assessment of patients. It's part of the way in which patients are
assessed and re-evaluated.

Essentially, you have to help people understand the importance of this type of patient
awareness. One place to start is to find out if in fact there have been suicides on
the medical units. If staff members are aware that this problem has occurred, that
makes it more real to them, as an issue that they must pay attention to. If there's
never been a suicide in that hospital, it would be much harder to get people's attention.
Talk to the intensivists or the people in the cardiac care units or cancer units or
places where you would expect to see [at-risk patients].

Q: What training about suicide risk is necessary for medical staff?

A: The training is one of detection and having a high index of suspicion. It's not to
prevent the act. The level of training should get the staff to the point where the
thought comes up, ‘I have to be a little bit more concerned about the risk
to this person,’ which would then increase the likelihood of obtaining a psychiatric
consultation. You would overwhelm the staff by saying they not only have to identify
suicidal patients, but also intervene, by talking with the person or getting the family
involved. You really only have to be able to identify the possibility to bring in
somebody with those particular skills to work with the person or to decide whether
it's a serious issue or not.

Q: Any other advice for hospitalists about this issue?

A: Again, it is increasing the clinician's index of suspicion. Somebody who has had a
serious stroke or heart attack or the initial diagnosis of cancer—probably
if they're going to commit suicide, they will not commit suicide in the hospital.
It's something that they are at risk for when they leave the hospital. The advice
would be when you're dealing with a patient who's had a potentially life-changing
physical problem, or is having an ongoing problem that appears to be wearing them
down—specifically things such as chronic pain or cancer—it's worthwhile
to at least be asking the question of ‘How is the person adjusting? How are
they handling it?’ Then an appropriate referral can be made.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.